Patterns of antibiotic use for acute respiratory infections in under-three-year-old children in India: A cross-sectional study

Background Despite its mostly viral etiology, antibiotics are frequently used to treat acute respiratory infections (ARIs) in children. India is one of the largest global consumers of antibiotics and has one of the highest rates of resistance to antimicrobial treatments. However, the epidemiology of antibiotic treatment among young children in India is poorly understood. Methods Using nationally representative household survey data from the Indian National Family Health Surveys (NFHS) conducted between 2015 and 2016 and 2019 and 2021, we estimated the prevalence of antibiotic use among 17 472 children under the age of three who reported ARI symptoms within two weeks before their mothers were interviewed. To assess the factors associated with antibiotic use for the treatment of ARI symptoms, we used multivariable logistic regression models that included sociodemographic, child-related, household, and health care related characteristics, with results reported on the prevalence difference (PD) scale. Results We estimated that 18.7% (95% CI = 17.8-19.6) of under-three-year-old (U3) children who exhibited ARI symptoms in the two weeks prior to the survey were given antibiotics as a treatment. The highest prevalence was observed in the southern and northern geographic zones of India. Furthermore, multivariable regression models indicated that children with greater access to health services were more likely to receive antibiotics for ARI treatment, regardless of the type of health care facility (public, private or pharmacy/unregulated). Additionally, the prevalence of antibiotic consumption was higher among children from families with religious affiliations other than Muslim and Hindu backgrounds (i.e. Christian, Sikh, Buddhist/neo-Buddhist, Jain, Jewish, Parsi, no religion and other) (PD = 11.7 (95% CI = 6.3-16.7)) compared to Hindu families and among mothers with a secondary or higher education (PD = 5.8 (95% CI = 1.7-9.9)) compared to mothers lacking formal education. Conclusions Our findings provide an important baseline for monitoring the use of antibiotics for the treatment of acute respiratory infections, and for designing interventions to mitigate potential misuse among young children in India.


Toilet facility
Categorized as improved (flush toilet, flush to piped sewer system, flush to septic tank, flush to pit latrine, flush to pit latrine, pit toilet latrine, ventilated improved pit latrine, pit latrine with slab and composting toilet) or unimproved (dry toilet, flush to somewhere else, flush to don't know where, pit latrine without slab/open pit, no facility, no facility/bush/field.Other answers were recoded as missing observations.

Type of cooking fuel
Categorized as clean (gas, liquefied petroleum gas/natural gas, and electricity) or unclean (kerosene, coal/lignite, charcoal, wood, straw/shrubs/grass, agricultural crop waste, and dung cakes).Other answers were recoded as missing observations.

Below Poverty Line (BPL) card
Whether the family possess or not a BPL ration card.The threshold is specified by each state government, BPL families receive 10kg to 20kg of food grains per family per month at 50% of the economic cost.

Hand hygiene
Presence of soap or detergent at the place where the household washes their hands.

Smoke exposure
Frequency of household members smoking inside the house, Categorized as never, daily, weekly, or less.

Age
Age of the child in months at the time of the interview.Calculated from century month code (CMC) and century day code (CDC) for NFHS-4 and NFHS-5, respectively.

Sex
Gender of the children assessed as male or female.Birth order Order in which the child was born.

Place of delivery
Place where the child was delivered.Categorized as public (including government/municipal hospital, government dispensary, union health complex, union health and family welfare center, community health center/rural hospital/block public health center, and other public health centers or sub-center facilities), private (including private hospital, clinic, maternity home, or other private sector health facility), at home (including respondent's home, parents' home, or other home) and NGO/Other health facilities.

Stunting
Used as a proxy for chronic undernutrition.Defined as per the new WHO Child Growth Standards as height-for-age.Classified as severely stunted if > -3.0 or moderately stunted if > -2.0 below the mean or not stunted.

Wasting
Used as a proxy for acute malnutrition.Defined as per the new WHO Child Growth Standards as weight-for-height.Classified as severely wasted if > -3.0 or moderately wasted if > -2.0 below the mean or not wasted.

Access to healthcare
Composite variable scoring the number of problems that the mother reported when getting medical help.It ranges from 0 to 8.Each of the following problems scores 1 point: getting permission to go, getting money needed for the treatment, distance to the health facility, having to take transport, not wanting to go alone, concern there is no female health provider, concern there is no provider, concern there are no drugs available.

4
Health worker visit in last 3 months Whether the respondent had met with an Anganwadi worker, Asha, or other community health worker in the last 3 months before the interview.

Health insurance
Whether the respondent is covered by any health scheme or any health insurance.

Vaccination card
Whether the child has a vaccination card, and the mother was able to show it to the interviewer.Categorized as: no card; yes, seen, and yes, not seen.

Fully immunized
Whether the child has received three doses of DPT vaccine, three doses of polio vaccine, a measles vaccine, and a BCG vaccine.

Anganwadi or ICDS benefits
Whether the child received benefits from Anganwadi/ICDS center in the last 12 months before the interview.

Medication for intestinal parasites
Whether the child received drugs for intestinal parasites in the last 6 months prior to the interview.

Iron supplementation
Whether the child received iron supplementation in the last 7 days prior to the interview.

Vitamin A supplementation
Whether the child received vitamin A supplementation in the last 6 months prior to the interview.

Place where first sought advice or treatment
Place where the mother first sought advice or treatment for ARI symptoms.Categorized as no treatment, public (including government/municipal hospital, government dispensary, union health and family welfare center, community health center/rural hospital/block public health center, additional public health centers or sub-center facilities, government mobile clinic, camp, NGO or trust hospital/clinic, Anganwadi/ICDS center, Asha or other public health facilities), private (including private hospital, clinic, paramedic or other private sector health facility) and pharmacy/unregulated (including pharmacy/drugstore, public or private traditional Ayush treatment, traditional healers, shop, friend/relative or other unauthorized sources).

Days after treatment
Number of days after the onset of cough symptoms until treatment or advice was sought.Categorized as same day, one, two, three, or four or more days.Amount offered to drink Amount offered to drink during the ARI episode.Categorized as no drink, less, same, or more than usual.Amount offered to eat Amount offered to eat during the ARI episode.Categorized as no drink, less, same, or more than usual.

Unweighted descriptive analysis
Table S2.Distribution of unweighted sociodemographic characteristics, household variables, child-related variables, and healthcare variables of under-three-year-old children with symptoms of ARI in the two weeks preceding the survey interview; NFHS-4 and NFHS-5; N = 16,972.

Figure S1 .
Figure S1.Prevalence of under-three-year-old children who received antibiotics to treat acute respiratory infection symptoms according to the zone of India.Bars correspond to 95% confidence intervals and the dashed line represents the mean value.

Figure S2 .
Figure S2.Prevalence of antibiotic treatment for under-three-year-old Indian children with symptoms of acute respiratory infections in the previous two weeks, stratified by zone; NFHS-4 and NFHS-5; N = 17,452.

Figure S3 .
Figure S3.Prevalence of under-three-year-old children who received antibiotics to treat acute respiratory infection symptoms according to the state or union territory.Bars correspond to 95% confidence intervals.

Table S3 .
Description of treatment-seeking behavior by mothers of under-three-year-old children with symptoms of ARI in the two weeks preceding the survey interview; NFHS-4 and NFHS-5; N = 16,972.
ARI: acute respiratory infection

Table S4 .
Prevalence of antibiotic treatment for under-three-year-old Indian children with symptoms of ARI in the previous two weeks by zones and state/union territory; NFHS-4 and NFHS-5; N = 17,452.